Immediate Evaluation and Management of This 13-Year-Old with Asthma and Acute Illness
This patient requires urgent assessment for acute severe asthma with immediate administration of nebulized albuterol and oral prednisolone, while simultaneously evaluating for possible appendicitis given the right lower quadrant pain, nausea, vomiting, and fever. 1
Critical Initial Assessment
Assess asthma severity immediately by evaluating:
- Ability to complete sentences in one breath (inability indicates severe asthma requiring urgent intervention) 2
- Respiratory rate (>25 breaths/min indicates severe asthma) 2
- Heart rate (>110 beats/min suggests severe disease) 2
- Peak expiratory flow if possible in a 13-year-old (<50% predicted indicates severe asthma) 2
The presence of vomiting during an asthma presentation is particularly concerning as it indicates either a severe attack or inability to tolerate oral medications, and significantly lowers the threshold for hospital admission. 1
Immediate Asthma Treatment
Administer nebulized albuterol 5 mg (full adult dose for children >2 years weighing >15 kg) via oxygen-driven nebulizer immediately. 2, 3
Give oral prednisolone 1-2 mg/kg (maximum 40 mg) immediately - this is critical as corticosteroids require 6-12 hours to manifest anti-inflammatory effects. 2
However, if vomiting persists or worsens, switch to intravenous hydrocortisone 200 mg every 6 hours instead of oral corticosteroids, as the patient cannot reliably absorb oral medications. 1
Reassess peak expiratory flow 15-30 minutes after nebulizer treatment to determine response. 2, 1
Critical Red Flag: Right Lower Quadrant Pain
The combination of right lower quadrant cramping pain, nausea, vomiting, fever, and decreased appetite raises serious concern for appendicitis, which can coexist with respiratory symptoms. 1
Perform immediate abdominal examination focusing on:
- Rebound tenderness in the right lower quadrant
- Guarding or rigidity
- McBurney's point tenderness
- Rovsing's sign
This patient may require urgent surgical consultation if peritoneal signs are present, regardless of respiratory symptoms. The gastrointestinal symptoms preceded by fever and appearing "a couple of days ago" suggest this is not simply asthma-related vomiting. 1
Antibiotic Decision
Do not prescribe antibiotics for the respiratory symptoms alone. The yellow-green nasal mucus and productive cough with yellow-clear sputum do not reliably distinguish bacterial from viral infection, and viral upper respiratory infections commonly trigger asthma exacerbations. 4
Antibiotics should only be given if bacterial infection is clearly documented (e.g., confirmed pneumonia on chest radiograph or bacterial appendicitis). 4
Critical Safety Considerations
Absolutely avoid sedatives including Benadryl (diphenhydramine) for this patient. The patient has been taking Benadryl, which is contraindicated in acute asthma as sedatives worsen respiratory depression and increase mortality risk. 1, 5
Discontinue Benadryl immediately and counsel the family that antihistamines with sedating properties are dangerous during asthma exacerbations. 1
Disposition Criteria
Arrange immediate hospital admission if any of the following are present: 2, 1
- Peak flow <50% predicted after initial nebulizer treatment
- Inability to complete sentences
- Persistent vomiting preventing oral medication
- Signs of peritonitis suggesting appendicitis
- Respiratory rate >25 breaths/min or heart rate >110 beats/min after treatment
Lower threshold for admission applies because: 2
- Symptoms began "a few days ago" suggesting progressive worsening
- Patient is vomiting and cannot reliably take oral medications
- Concerning abdominal symptoms requiring surgical evaluation
If Discharge is Appropriate (Mild Exacerbation Only)
Continue prednisolone 1-2 mg/kg daily for up to 5 days. If not better after 5 days, immediate hospital referral is required. 2
Step up regular inhaled corticosteroid therapy as the need for rescue albuterol indicates inadequate chronic asthma control. 2
Provide written asthma action plan and ensure follow-up within 24-48 hours. 2, 1
Common Pitfalls to Avoid
Do not attribute all symptoms to asthma - the right lower quadrant pain with fever, vomiting, and anorexia suggests a surgical abdomen that requires separate evaluation. 1
Do not continue Robitussin and Benadryl - these over-the-counter medications do not treat the underlying airway inflammation and Benadryl is contraindicated. 1, 5
Do not delay corticosteroids - the patient has been symptomatic for "a few days" without systemic corticosteroids, allowing inflammation to worsen. 2
Do not assume yellow-green mucus means bacterial infection requiring antibiotics - this commonly occurs with viral infections that trigger asthma. 4